An Infant With Recurrent Vomiting With Solid Food.

Question: An 11-month-old female infant was evaluated for a history of recurrent emesis. These episodes started soon after weaning with the introduction of solid foods. Early cyanotic crying followed by repeated vomiting of undigested foods characterized each solid feeding, ceasing when all food was ejected. On the other hand, the infant’s growth was excellent with breast milk and blended or fluid foods. The baby never coughed during feedings, and she never complained of any low airway infection. The patient was born at term after a healthy pregnancy. On admission, her physical examination and laboratory tests were unremarkable. A barium swallow (Figure A) was undertaken, confirming our suspicion. What is the cause of this patient’s recurrent vomiting? Furthermore, what is the following management? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The barium swallow (Figure A) showed a tapered esophageal narrowing in the distal esophagus, independently from esophageal peristalsis, followed by a mild dilation. Computed tomographic angiography was undertaken to rule out external causes of mechanical compression. Finally, the upper gastroesophageal endoscopy demonstrated a third distal esophagus eccentric sub-stenosis, covered by normal mucosa, and a diagnosis of congenital esophageal stenosis (CES) was made (Figure B). CES is a rare condition, affecting 1 in 25,000 to 50,000 live births, with unknown etiology, probably due to an embryonic failure. It can be isolated or in 50% of the cases associated with other anatomic malformations such as esophageal atresia, tracheoesophageal fistula, and cardiovascular defects.1Michaud L. Coutenier F. Podevin G. et al.Characteristics and management of congenital esophageal stenosis: findings from a multicenter study.Orphanet J Rare Dis. 2013; 8: 186Crossref PubMed Scopus (45) Google Scholar, 2Harmon C.M. Coran A.G. Congenital anomalies of the esophagus.in: Coran A.G. Adzick N.S. Krummel T.M. Pediatric Surgery. 7th ed. Elsevier, Philadephia2012: 893-918Crossref Scopus (35) Google Scholar, 3Suzuhigashi M. Kaji T. Noguchi H. et al.Current characteristics and management of congenital esophageal stenosis: 40 consecutive cases from a multicenter study in the Kyushu area of Japan.Pediatr Surg Int. 2017; 33: 1035-1040Crossref PubMed Scopus (16) Google Scholar While all patients complain of vomiting, solid dysphagia and food impaction, other symptoms, such as respiratory distress and cyanosis, are also reported. The diagnosis is delayed around the first year of life, especially when the stenosis is isolated, because the first symptoms appear after weaning.1Michaud L. Coutenier F. Podevin G. et al.Characteristics and management of congenital esophageal stenosis: findings from a multicenter study.Orphanet J Rare Dis. 2013; 8: 186Crossref PubMed Scopus (45) Google Scholar,3Suzuhigashi M. Kaji T. Noguchi H. et al.Current characteristics and management of congenital esophageal stenosis: 40 consecutive cases from a multicenter study in the Kyushu area of Japan.Pediatr Surg Int. 2017; 33: 1035-1040Crossref PubMed Scopus (16) Google Scholar Achalasia, gastroesophageal reflux disease, vascular rings, and eosinophilic esophagitis should be kept in mind in the differential diagnosis.2Harmon C.M. Coran A.G. Congenital anomalies of the esophagus.in: Coran A.G. Adzick N.S. Krummel T.M. Pediatric Surgery. 7th ed. Elsevier, Philadephia2012: 893-918Crossref Scopus (35) Google Scholar In consideration of the type of CES, it can be managed either minimally invasively with endoscopic ballooning or surgically.1Michaud L. Coutenier F. Podevin G. et al.Characteristics and management of congenital esophageal stenosis: findings from a multicenter study.Orphanet J Rare Dis. 2013; 8: 186Crossref PubMed Scopus (45) Google Scholar, 2Harmon C.M. Coran A.G. Congenital anomalies of the esophagus.in: Coran A.G. Adzick N.S. Krummel T.M. Pediatric Surgery. 7th ed. Elsevier, Philadephia2012: 893-918Crossref Scopus (35) Google Scholar, 3Suzuhigashi M. Kaji T. Noguchi H. et al.Current characteristics and management of congenital esophageal stenosis: 40 consecutive cases from a multicenter study in the Kyushu area of Japan.Pediatr Surg Int. 2017; 33: 1035-1040Crossref PubMed Scopus (16) Google Scholar Our patient was effectively treated with monthly ballooning dilations (Figure C), restoring esophageal patency without complications (Figure D). Soon after, the baby started a semi-solid diet, and in a few months she achieved a complete tolerance for solid foods.